Care Home: Worcester Road, 38

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What the care home does well People living in the home are able to pursue placements in employment and enjoy day centre activities in accordance with their personal preferences. The home is in a community setting, with access to local facilities and transport. There is a consistent care staff team which has helped to provide continuity for the people living in the home. What has improved since the last inspection? People living in the home had previously been restricted in accessing food and drinks without the involvement of staff. They now have the opportunity to develop their independent daily living skills. Staff are making efforts to make the home`s environment more suitable to meet the needs and wishes of the people living there. The stair carpet has been replaced and the outstanding remedial work on the ground floor shower room completed. CARE HOME ADULTS 18-65 Worcester Road, 38 Cowley Uxbridge Middlesex UB8 3TH Lead Inspector Jane Collisson Key Unannounced Inspection 19th May 2008 12:10 Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Worcester Road, 38 Address Cowley Uxbridge Middlesex UB8 3TH 01895 272794 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.mencap.org.uk Royal Mencap Society Manager post vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one service user, currently living there, who is aged above 65 years. 20th September 2007 Date of last inspection Brief Description of the Service: Worcester Road is a registered home, providing personal care to seven service users with a learning disability. It is located off Cowley High Street, in a residential area, close to shops, public transport and other amenities. The shopping centre of Uxbridge can be reached by public transport and the home has its own transport. There are seven single bedrooms, two on the ground floor and five on the first floor. The communal areas comprise of a lounge, dining room, kitchen and laundry room. A shower room and toilet are available on the ground floor and the first floor has a bathroom and toilet, separate shower room, and a third toilet. The office/sleeping-in room is on the first floor. There is a front garden, with parking, and a lawned garden to the rear. Street parking is available in Worcester Road and the surrounding area. Dimensions Housing Association owns the premises and the Royal Mencap Society manages the home. The staff team consists of a manager, deputy manager and a team of support workers. They provide support with personal care, practical tasks and activities. The fees, at the time of the inspection, ranged from £513.36 to £800.69. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection commenced on the 19th May 2008 between the hours of 12.10pm and 5.35pm. The Acting Manager was present. She is in the process of applying to become the Registered Manager and has worked in the home since 2006. She had returned from maternity leave in March 2008. In her absence, the home had part-time management from two Mencap staff. An unannounced, random inspection was carried out on 28th February 2008 to check on the progress of some of the requirements of the September 2007 inspection. There had been concerns about the continuing suitability of the placements of two of the people living in the home. Since then, one person has moved to another home and Social Services assessment has now been undertaken with the other person. The environmental changes, which would be needed to enable the person to stay in the home, are not being considered. Three members of the care staff were met. One member of staff, in additional to the Manager, was on the early shift and two staff were on the late shift. There are now two staff on each shift, between 7.30am and 9pm, with one member of staff sleeping in at night. This has been an improvement on the staffing levels at the September 2007 inspection, when there was only single staff cover for a busy part of the day. All six of the people living in the home were met. Two were in the home during the afternoon. They were relaxing in the dining area of the home and enjoying listening to music. Four people returned later from their respective work and day centre placements. There was a pleasant and relaxed atmosphere in the home. People were being supported to make choices about how they spent their time. Staff were cooking an evening meal and one person was to laying the table. Redecoration of the main lounge was taking place, by the staff. They were also looking, at the request of one person, for a pool table. Other items were to be sought to make the room more user-friendly for the residents. Since the last resident left, there have been no specific cultural needs to be met. As well as discussion with people living in the home and staff, we examined a variety of records including the care plans of the people living in the home, staff and training records, maintenance and complaints. The Commission for Social Care Inspection’s Annual Quality Assurance Assessment had been completed shortly before the September 2007 inspection but was completed by staff who were unfamiliar with the home and so had limited information. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 6 All of the Key Standards were assessed during this inspection. The majority of the twenty requirements made at the previous two inspections have now been met. There are now seven requirement, three of which are repeated. What the service does well: What has improved since the last inspection? What they could do better: We found that the Statement of Purpose and Service Users Guide still needed to be updated, in accordance with the Care Home Regulations 2001, so that prospective residents have all of the information they require. Consideration should be given to providing the information in visual formats to suit the people living in the home. People should also have the information regarding the terms and conditions, fees and facilities provided. The number of staff on duty does not always support the people receiving the service to have the opportunity for spontaneous outings or to go out on a oneto-one basis. The Registered Providers need to ensure that there is evidence of a regular review of the staff numbers, particularly when the vacant room is filled, to ensure individual needs are met. We did not find that we could assess fully the induction and training staff had received, or look at the plans for their future development. The Manager needs to ensure that the records are available for inspection to evidence that training has been completed and is suitable to meet the needs of the residents. We found that the opportunity to undertake National Vocational Qualifications training was not being made available. The Registered Providers need to Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 7 demonstrate that they are working towards achieving the target of having 50 of the staff trained. A full fire risk assessment is needed that takes into account the potential risks to the residents and staff. This includes assessing the safety of the electrical cupboard under the stairs and adhering to the regular checks of all equipment. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information to help people to make a decision about moving to the home and its facilities, is not up-to-date or in an accessible format. People do not have access to the terms and conditions of the home. Assessment procedures are in place should any prospective residents be referred. EVIDENCE: We discussed with the Manager that the Service Users Guide and Statement of Purpose were still required to be brought up to date. In particular, the Statement of Purpose needs to explain how the needs of the people living in the home are met, particularly in relation to the staffing levels, facilities and activities. The Service Users Guide has some photographs but could be in a more user friendly style to suit the individual communication needs of the people living in the home. One of the people living in the home had recently left the service and there is one vacancy. As no new people have been admitted since the last inspection, the Standard could not be fully assessed. However, we found that the Manager was aware of the assessment procedures should a referral be received. The Manager said that she had had enquiries about the room, but no formal referrals. The relative of one prospective resident had made an informal visit to the home. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 10 It has been an outstanding requirement that the terms and conditions for the home should be available to every person living there and a copy should be in the Service Users Guide for prospective residents. We were not able to find copies of these. The people living in the home do have tenancy agreement with the owners of the house, but should have information on the fees, other charges and facilities they can expect from the Registered Providers. This requirement is repeated. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are involved in their own care planning and help to develop person centred plans. Regular reviews take place. People are supported to make decisions about their daily lives and involved in the daily life of the home. EVIDENCE: We examined four of the care planning files of the people living in the home. This included a file for each person, based on a person centred care plan. These included photographs of all aspects of the person’s life. We found that the residents did not have their own copies and it is recommended that these are copied so that people can keep their own file. We noted that there have been improvements to the way in which the files are maintained but are still very full and would benefit from archiving and streamlining. Care plans are reviewed but we were informed that Social Services representatives are no longer attending the annual reviews. However, one Social Services assessment has now taken place for a person whose needs can Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 12 no longer be met by the facilities of the home. A more suitable placement is being sought. We saw risk assessments in the files in respect of the activities that the people living in the home undertake. These included bathing, travelling and medication. We noted, however, that some were undertaken in 2006 and these need to be seen to have been reviewed even if not needing updating. All of the people in the home are able to make decisions about how they spend their time and what activities they like to pursue. We found that there is now more opportunity for them to develop their independent living skills and participate fully in the life of the home. Three of the people are able to go out independently and are encouraged to fulfil their wishes with regards to work placements and meaningful activities. We found that people have good communication with the staff, who know the residents well. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the opportunity to attend varied day activities, including the chance to go work placements. Holidays are planned, although there is less opportunity for spontaneous outings. The involvement of family and friends is welcomed. EVIDENCE: Most of the people living in the home are quite independent and were seen to help around the house. We observed one person laying the dining table for the evening meal and another person was helping a member of staff to clear items, ready to have the lounge redecorated. Now that the food is being stored in the kitchen, the opportunities for developing skills should be easier to maintain. We saw, on the office wall, information about all of the activities that people living in the home enjoy on a weekly basis. Everyone attends some day Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 14 activities, from one day at an older persons’ centre, to four days a week at a day centre. Two people have employment and spoke about this. This includes working at a hotel and a nursery. One person had been employed for many years at one company, but this had unfortunately closed. We talked to two people about their holidays and one was looking forward to a “break from work” to go on a holiday with family members. It is planned that all of the people in the home will have the opportunity to attend a holiday of their choice this year. People have enjoyed visits to the cinema and theatre and two of the residents have participated in horse riding and playing pool. There had been a recent outing to Henley to attend “banger racing”. One person visits an evening club and another one at weekends. Photographs and information about their favourite activities are included in the new person centred plans. The home is located in a residential area, and is fairly close to local amenities and to public transport. The home has its own transport and the manager said that most staff are able to drive, so there is not a problem in using it. However, we did discuss with the Manager that the current staff levels, although improved from last year, do not make spontaneous outings very easy for those people who need to be accompanied. The staff do make the most of the weekdays when people are at home, and known outings are planned for, with extra staff being placed on the rota. If the vacancy for a new resident is filled, the Registered Providers will need to look at any effect that the additional person may have on the provision of activities and outings and ensure that people still have the level of activities they need. The staff were in process of making the large lounge into a room more suited for indoor leisure pursuits, including trying to purchase a pool table which had been the choice of one of the residents. People seem to have preferred gathering in the dining area, or staying in their rooms, so the room was not often used as a sitting room. Those people living in the home who have families are supported to stay in touch and their families are welcome to visit the home. One relative was seen on the visit to the home in February 2008. Another person goes regularly to stay with family at weekends and others have been on holiday with their families. They are invited to attend reviews. The home’s cat had sadly died since the last inspection but we found people would discuss this and had obviously been supported to understand and accept their loss. We saw a meal of sausages, onions, cauliflower, carrots, baked beans, and potatoes being prepared by the staff member on duty. Copies of past menus were seen and there appears to be a balanced and varied diet. Where people can prepare their own snacks, they are encouraged to do so. We were concerned at the last two inspections that people did not have easy access to preparing snacks and drinks, due to difficulties with one of the people living in the home. This has now been resolved and food and drinks are freely available to those able to prepare their own. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 15 The staff were seen to have worked with a previous resident to encourage a connection, by personalisation of the bedroom and by accessing culturally appropriate food. There were no specific cultural or religious needs required to be met in the home. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported with their health needs and receive personal care appropriate to the needs. Medication procedures are in place to ensure administration is satisfactory. Specialist health services are accessed where this support is needed. EVIDENCE: There was information in the files regarding personal care needs. There is an intimate care policy. The home has, at present, one male staff member so that same gender care can be provided. We saw records of the health needs, which are met by visits to local community services. The records evidenced that a number of services, such as chiropody, dentists and general practitioners have been accessed as required. More specialist help, such as psychology, was seen to have been accessed where it is needed. All but one of the people living in the home has good mobility, which is needed to access the first floor facilities. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 17 We checked the medication cupboard and found that the medication administration was in good order. It had been a requirement for the home to cease to “double dispense” the medication into pots in September 2007 and the Manager confirmed that this was not being done. A 28 day blister pack system in use for the dispensing of medication. Photographs and details of the medication for each person were in the medication file. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are aware of being able to make complaints. Safeguarding adults training is being updated and staff are being supported to understand the procedures. People are supported to manage their own money wherever possible and there are safeguards in place. EVIDENCE: There had been two complaints since the last key inspection, made by family members, regarding the behaviour of one of the people living in the home. These concerns have now been resolved. Safeguarding Adults training was due to be held for the staff team later in the week of the inspection. The Manager also said that she would also be discussing the issue at the future staff meetings, including the information on when to report to the Commission for Social Care Inspection under Regulation 37. There had been a number of issues, while the Manager was on leave which, although sometimes reported, had not been acted upon sufficiently promptly. There were delays in finding a suitable placement for a person which had resulted in an unsettling time for all of the people concerned. We found that there are systems in place to help to safeguard people with their finances and a sample of the documentation was examined. Information was seen about each person’s financial arrangements. Each person has a detailed plan of their finances, although they appeared to be seen to need updating. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 19 One person is supported to manage their finances independently. are kept in an orderly manner. Receipts Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the environment and facilities to meet the needs of the majority of the people living in the home. Action is being taken where it is recognised that needs cannot be accommodated. The home is clean and comfortable. Bedrooms are nicely personalised and meet the needs of the people using them. EVIDENCE: We found that the staff had commenced painting the large, but underused, lounge. The room is quite dark, due to high hedges and a wall close to one of the windows, and the staff were painting the lounge white. The staff said that they will be making it into more of a leisure room, with various activities and, possibly, sensory equipment. The dining room is located off the kitchen, and is used by most of the people living in the home. One of the armchairs is still in need of replacing or recovering and this needs to be considered. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 21 At the February 2008 inspection we were pleased to note that the stair carpet, which was potentially dangerous, had been replaced. The front garden was neat and tidy with flower beds. The back garden was rather overgrown, but this was due to gardener not being able to gain access. He was due to come back to complete this. There has been some redecoration of bedrooms in the last year and the rooms seen were nicely decorated and personalised. We spoke to some of the residents who confirmed that they had chosen their colours and the rooms were as they wished them. People have the television and music facilities that they wish and some people were seen to spend time in their rooms enjoying these. There are three bathrooms for the use of seven people and the staff. The one of the ground floor is a shower room and toilet but is not easily accessible to one of the residents. It has been decided that no changes can be made to accommodate the person and arrangements were being made to find alternative accommodation. The outstanding work that was needed on the ground floor shower room floor, which was leaking, and a damp wall, had been carried out by the February 2008 visit. There is a bathroom and a shower room on the first floor, with an additional toilet. We found that the laundry, which is located on the ground, floor has still not been decorated. For hygienic reasons, the walls should be impermeable and easy to clean. This should be included in the future refurbishment budget. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a consistent staff team, which has helped to support the people living in the home through some difficult times. Staff training takes place, but the records do not evidence that it has all been undertaken or is up-to-date. Insufficient funding is available to promote the staff undertaking National Vocational Qualifications. Staff recruitment is generally satisfactory but needs to be checked to ensure that the records are all accurate. EVIDENCE: We found that the all of the staff had been in post at the previous inspection in September 2007, which has provided good consistency for the people living in the home. As there are only two staff on each shift, most of the staff undertake all of the duties in the home. Although there have been several changes in management, staff were positive about working in the home. The Manager is now working for 30 hours a week, over four days. She has a Deputy Manager and it was discussed with her that sufficient management training should be available to the Deputy Manager to ensure that she is able to deputise, particularly now that the Manager is not full-time. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 23 The training records were not sufficiently up-to-date to show that all of the staff had all of their current training needs met. We looked at information in the staff files with regard to training and found that basic training appeared to have been undertaken. We were informed that there had been an organisation previously which had carried out all of the training and maintained the records. This has now changed and the records needed to be improved to evidence that needs are being met. Some of the refresher training is now undertaken using distance learning systems, on the computer. Although no new staff have been employed, we discussed with the Manager about the company’s induction. We found that the records are not kept in the home. It is part of the Care Home Regulations 2001 that there is evidence of the induction procedures and these need to be available for inspection. There have been no appraisals undertaken in the absence of the Manager to identify the training and development needs of the staff. We noted that there is no equality and diversity training and this should be considered by the company. Following concerns raised at the Inspection in September 2007, the hours of staff were extended and there are now two staff on duty between 7.30am and 9pm. There is single staff cover between the hours of 9pm and 7.30pm and the staff member sleep in. The Manager said that the home is now fully staffed and no agency staff are used. Where cover is needed, there are relief staff to call upon. We examined a sample of the three recruitment records. While these were found to be mostly satisfactory, there was information on a form regarding a Criminal Records Bureau disclosure which was ambiguous and the Manager undertook to check this with her Head Office. At the present time, only two staff have National Vocational Qualifications. It was reported that there is no funding available for National Vocational Qualifications unless free funding can be found. We discussed with the Manager that the home should be meeting the National Minimum Standards of having 50 of the staff trained to Level 2 or above. The Registered Providers need to look at ways in which staff can achieve a qualification and develop their skills. This is a repeated requirement. Staff are supported with monthly meetings and, since the Manager has returned, she has undertaken supervision with all of the staff. There were gaps previously and the home had not met the National Minimum Standard of six a year. She said that she will also be completing the staff appraisals, together with the development and training plans. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is qualified to run the home and is aware of the work needed to being everything up to a good standard. A more settled period of management should support the staff team to develop the service. Health and safety has improved. The views of the people living in the home are taken into account but more work is needed to further develop the service. EVIDENCE: The current Manager has worked in the home since May 2006 but was on maternity leave from January 2007 until March 2008. She has some previous management experience and has worked for Mencap for nine years. She has a National Vocational Qualification Level 3 and the Registered Managers Award. The home has been without a Registered Manager since 2004 and had two temporary managers in the interim period. The Manager has commenced the Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 25 process of applying for registration with the Commission for Social Care Inspection. Staff were more positive about the home than at previous inspections and said that there has been a good team for the past two years. A good rapport was noted between the staff and the people who live in the home. The Manager reported that surveys had been undertaken with the residents but these have been incorporated into a report covering more than Worcester Road. As the people living in the home are able to express their views, it is recommended that further work is carried out to demonstrate that their views are being sought on the quality of life in the home. This has been partially demonstrated by the work being carried out in the lounge but could be extended. The Commission for Social Care Inspection’s Annual Quality Assurance Assessment had been completed before the 2007 inspection but had limited information as the management staff were temporary and had limited experience of the home. A health and safety issue was raised at the last two inspections but has still not been completed. There is no door on the cupboard which houses the electrical equipment, only a curtain. For safety, both to prevent the equipment being touched, and to prevent the risk of fire, a suitable door needs to be fitted. Battery operated devices have now been fitted to the bedroom doors to ensure that people should be safeguarded should the fire alarm be activated. We did find that there was no evidence of the devices being checked although the health and safety information indicated that these should be done weekly. The remainder of the fire records were in order. Fire alarms are checked weekly and they were last serviced in April 2008. The emergency lighting was checked in February 2008. Three fire evacuations had been undertaken since November 2007. At the last inspection there was a requirement that the fire risk assessment was completed and we found that this is still outstanding. It is required to the current fire legislation (Regulatory Reform [Fire Safety] Order 2005) which came into force in October 2006. We examined the maintenance files and found that the hot water had been tested in all of the rooms in May 2008. This has been the subject of a previous requirement when action had been needed to be taken when water temperatures were at a potentially unsafe level. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No 1 2 3 4 5 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4&5 Requirement The Statement of Purpose and Service Users Guide must be updated in accordance with the Care Home Regulations 2001 (Previous timescale of 30/11/07 not met) The Registered Providers must ensure that the residents are issued with terms and conditions. A copy of these must be included in the Service Users Guide. (Previous timescale of 30/11/07 not met) The Registered Providers must provide evidence of a regular review of the staff numbers to ensure that people living in the home have the opportunity for activities and outings to meet their individual needs. The Manager must ensure that the records which help to safeguard the people living in the home are accurate. The Manager must ensure that the records are available of staff development and training to evidence that training has been completed and is suitable DS0000027070.V364366.R01.S.doc Timescale for action 31/07/08 2 YA5 5 (1)(c) 31/07/08 3 YA12 16 (2)(m) 18 (1)(a) 31/07/08 4 YA34 17 (2) 19 (5) 18 (1)(c)(i) 30/06/08 5 YA35 31/07/08 Worcester Road, 38 Version 5.2 Page 28 6 YA35 18(1)(c)(i) 7 YA42 23 (4A)(b) 13 (4) to meet the needs of the residents. This includes the induction records. (Previous timescale of 31/2/07 not met) The Registered Providers must provide details how it will offer the staff the opportunity to undertake National Vocational Qualifications, in order for the home to meet to target of having 50 of the staff trained. The Registered Providers must ensure that the home has a full fire risk assessment and that an assessment of the home is made to minimise any risks to residents and staff. This includes the safety of electrical equipment under the stairs and the regular checks of all equipment. 31/07/08 30/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA30 YA39 Good Practice Recommendations That the person centred care plans can be copied so that the person concerned has a copy to keep. That the laundry is included in the next refurbishment budget for redecoration. That surveys are carried out specifically for Worcester Road residents so that the views of the people living in the home can help to improve the quality of care. Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Worcester Road, 38 DS0000027070.V364366.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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